NO PERMIT NUMBER (2)CERTIFICATION OF RE-CLAIMED WATER SYSTEMS c6�°0" CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS 'i' 'i- BACKFLOW PREVENTION VALVE EXPERT
INSTALLATION -REPAIRS -TESTING -CERTIFICATION
CALIFORNIA (800) 464 -FLOW (3569)
LOCAL (408) 269-2600 S q�e. LICENSED CONTRACTOR C.C.L.# 427328
FAX (408) 269-2650 3750-E CHARTER PARK DR., SAN JOSE CA 95136-1356
ACKFLOW PREVENTION SPECIALISTS, INC.
MAILING / OWNER �ertino City Center Bldgs SERVICE Cupertino City Center Bldgs
Address 20400 Stevens Creek Blvd #230 ADDRESS 20400 Stevens Creek Blvd.
Cupertino, CA. 95014 Cupertino, CA. 95014 D
CONTACT: Bob Camarda TEL# 408-410-6517 FEB 2 5 2008
MANUFACTURER MODEL NUMBER TYPE SIZE BE IAL NUMBER
Febco 805Y DC 2" 13
NEW INSTALLATION: ❑ REPLACEMENT:L]
REPLACEMENT DEVICE INFORMATION
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
INTERNAL® METER#
EXTERNAL ❑ TAG #
Hazard TVDe: cooling tower
•
LOCATION OF DEVICE chiller make up / heat exchanger roof
Comments:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
IFITIAL TEST B
REPAIRED BY
FINAL TEST BY
PASS
CERTIFIED TESTER NO. 11277 DATE 02/14/08 FAIL
MO. DAY YR.
DATE �'
,Z r "y PASS
CERTIFIED TESTER NO. �I? �7 DATE FAIL
MO. DAY YR.
REDUCED PRESSURE DEVICES
PRESSURE TYPE
Shutatt Valves
DOUBLE CHECK VALVES
VACUUM BREAKERS
DIFFERENTIAL
CHECK VALVE
CHECK VALVE
AIR INLET
CHECK VALVE
PRESSURE/RELIEF
N0.1
N0.2
VALVE
#1 p
CLOSED TIGHT ❑
CLOSED TIGHT ❑
OPENED AT_ LBS.
OPENED AT LBS
CLOSED TIGHT El
CLOSED TIGHT
INITIAL
TEST
N lbs.
# lbs.
OPENED UNDER 2.0
O
DID NO NDER I.O
R DID NOT OPEN [IrnLEA_KED
# LBS.
LEAKED ❑
OR DID NOT OPEN ❑
LEAKED ❑
REPAIRS
AND
1 (% I �4 (-C-
' ILEAKED
I ' �- 21
MATERIALS
USED
�
a`ec
S
FINAL
CLOSED TIGHT
CLOSED TIGHT
90XLSS
CLOSED TIGHT❑
TEST
'IV
�' Z
OPENED AT _NUBS
PENED AT
CLOSED TIGHT
NUBS
NUBS
Comments:
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
IFITIAL TEST B
REPAIRED BY
FINAL TEST BY
PASS
CERTIFIED TESTER NO. 11277 DATE 02/14/08 FAIL
MO. DAY YR.
DATE �'
,Z r "y PASS
CERTIFIED TESTER NO. �I? �7 DATE FAIL
MO. DAY YR.